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MEDICAL HISTORY PATIENT NAME ____________________________________________________________ Birth Date _____________________________________ Health issues and/or medications have a critical interaction(s) with dental treatment. Please answer the following questions about YOUR CHILD : Name of primary physician? _____________________________________________________Phone Number _______________________________ Is your child under a physician’s care now? Yes No If yes, please explain: _________________________________________ Has ever been hospitalized or had a major surgery? Yes No If yes, please explain: _________________________________________ Has had any complication with Anesthesia Yes No ___________________________________________________________ Has had a serious head or neck injury? Yes No If yes, please explain: _________________________________________ Is taking any prescription medications? Yes No If yes, please explain: _________________________________________ Is taking herbal supplements or other medications/drugs? Yes No Provide a list: _______________________________________________ ______________________________________________________________________ Is on a special diet? (Ex: gluten free) Yes No ___________________________________________________________ Needs antibiotic coverage before dental treatment? Yes No ___________________________________________________________ History of developmental problems and/or syndromes: ____________________________________________________________________________ History of learning disabilities: ________________________________________________________________________________________________ Birth defects or Genetic Disorders: ____________________________________________________________________________________________ Is allergic to the following Medications: ________________________________________________________________________________________________________________________ Has been diagnosed with any of the following? ADHD/ADD Yes No Autism spectrum Yes No AIDS/HIV Positive Yes No Diabetes Yes No Hepatitis A, C or B (mark) Yes No Kidney Problems Yes No Cerebral palsy Yes No Hearing loss Yes No Epilepsy Yes No Heart Murmur Yes No Congenital Heart Disorder Yes No Seizures Yes No Bleeding disorder Yes No Rheumatoid Arthritis Yes No Blood disorders Yes No Asthma Yes No MRSA Yes No Tuberculosis Yes No Has ever been diagnosed with any serious illness not listed above? Yes No If yes, please explain: ___________________________________ ________________________________________________________________________________________________________________________ Comments: _________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ For Patients 13 Years and Over: Do you use tobacco? Yes No Do you use controlled substances? Yes No Are you taking Birth control? Yes No Are you pregnant? Yes No To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in medical status. SIGNATURE OF PATIENT, PARENT, or GUARDIAN __________________________________________________ DATE ______________________
